| 1 |
BENE_ID |
Encrypted CCW Beneficiary ID |
| 2 |
CLM_ID |
Claim ID |
| 3 |
CLM_LINE_NUM |
Claim Line Number |
| 4 |
NCH_CLM_TYPE_CD |
NCH Claim Type Code |
| 5 |
CLM_THRU_DT |
Claim Through Date (FFS) |
| 6 |
TAX_NUM |
Line Provider Tax Number |
| 7 |
PRVDR_SPCLTY |
Line CMS Provider Specialty Code |
| 8 |
PRTCPTNG_IND_CD |
Line Provider Participating Indicator Code |
| 9 |
LINE_SRVC_CNT |
Line Service Count (FFS) |
| 10 |
LINE_CMS_TYPE_SRVC_CD |
Line CMS Type Service Code |
| 11 |
LINE_PLACE_OF_SRVC_CD |
Line Place Of Service Code (FFS) |
| 12 |
LINE_1ST_EXPNS_DT |
Line First Expense Date (FFS) |
| 13 |
LINE_LAST_EXPNS_DT |
Line Last Expense Date (FFS) |
| 14 |
HCPCS_CD |
Healthcare Common Procedure Coding System (HCPCS) Code (FFS) |
| 15 |
HCPCS_1ST_MDFR_CD |
HCPCS Initial Modifier Code (FFS) |
| 16 |
HCPCS_2ND_MDFR_CD |
HCPCS Second Modifier Code (FFS) |
| 17 |
HCPCS_3RD_MDFR_CD |
HCPCS Third Modifier Code (FFS) |
| 18 |
HCPCS_4TH_MDFR_CD |
HCPCS Fourth Modifier Code (FFS) |
| 19 |
BETOS_CD |
Line Berenson-Eggers Type of Service (BETOS) Code |
| 20 |
LINE_NCH_PMT_AMT |
Line NCH Medicare Payment Amount |
| 21 |
LINE_BENE_PMT_AMT |
Line Payment Amount to Beneficiary |
| 22 |
LINE_PRVDR_PMT_AMT |
Line Provider Payment Amount |
| 23 |
LINE_BENE_PTB_DDCTBL_AMT |
Line Beneficiary Part B Deductible Amount |
| 24 |
LINE_BENE_PRMRY_PYR_CD |
Line Primary Payer Code (if not Medicare) |
| 25 |
LINE_BENE_PRMRY_PYR_PD_AMT |
Line Primary Payer (if not Medicare) Paid Amount |
| 26 |
LINE_COINSRNC_AMT |
Line Beneficiary Coinsurance Amount |
| 27 |
LINE_PRMRY_ALOWD_CHRG_AMT |
Line Primary Payer Allowed Charge Amount |
| 28 |
LINE_SBMTD_CHRG_AMT |
Line Submitted Charge Amount |
| 29 |
LINE_ALOWD_CHRG_AMT |
Line Allowed Charge Amount |
| 30 |
LINE_PRCSG_IND_CD |
Line Processing Indicator Code |
| 31 |
LINE_PMT_80_100_CD |
Line Payment 80%/100% Code |
| 32 |
LINE_SERVICE_DEDUCTIBLE |
Line Service Deductible Indicator Switch |
| 33 |
LINE_ICD_DGNS_CD |
Line Diagnosis Code |
| 34 |
LINE_ICD_DGNS_VRSN_CD |
Line Diagnosis Code Diagnosis Version Code (ICD-9 or ICD-10) |
| 35 |
LINE_DME_PRCHS_PRICE_AMT |
Line DME Purchase Price Amount |
| 36 |
PRVDR_NUM |
DMERC Line Supplier Provider Number |
| 37 |
PRVDR_NPI |
DMERC Line-Item Supplier NPI Number |
| 38 |
DMERC_LINE_PRCNG_STATE_CD |
DMERC Line Pricing State Code (SSA) |
| 39 |
PRVDR_STATE_CD |
NCH Provider SSA State Code |
| 40 |
DMERC_LINE_SUPPLR_TYPE_CD |
DMERC Line Supplier Type Code |
| 41 |
DMERC_LINE_SCRN_SVGS_AMT |
DMERC Line Screen Savings Amount |
| 42 |
DMERC_LINE_MTUS_CNT |
DMERC Line Miles/Time/Units/Services (MTUS) Count |
| 43 |
DMERC_LINE_MTUS_CD |
DMERC Line Miles/Time/Units/Services (MTUS) Indicator Code |
| 44 |
LINE_HCT_HGB_RSLT_NUM |
Hematocrit/Hemoglobin Test Results |
| 45 |
LINE_HCT_HGB_TYPE_CD |
Hematocrit/Hemoglobin Test Type Code |
| 46 |
LINE_NDC_CD |
Line National Drug Code (NDC) (FFS) |
| 47 |
LINE_OTHR_APLD_IND_CD1 |
Line Other Applied Indicator 1st Code |
| 48 |
LINE_OTHR_APLD_IND_CD2 |
Line Other Applied Indicator 2nd Code |
| 49 |
LINE_OTHR_APLD_IND_CD3 |
Line Other Applied Indicator 3rd Code |
| 50 |
LINE_OTHR_APLD_IND_CD4 |
Line Other Applied Indicator 4th Code |
| 51 |
LINE_OTHR_APLD_IND_CD5 |
Line Other Applied Indicator 5th Code |
| 52 |
LINE_OTHR_APLD_IND_CD6 |
Line Other Applied Indicator 6th Code |
| 53 |
LINE_OTHR_APLD_IND_CD7 |
Line Other Applied Indicator 7th Code |
| 54 |
LINE_OTHR_APLD_AMT1 |
Line Other Applied Amount for 1st Code |
| 55 |
LINE_OTHR_APLD_AMT2 |
Line Other Applied Amount for 2nd Code |
| 56 |
LINE_OTHR_APLD_AMT3 |
Line Other Applied Amount for 3rd Code |
| 57 |
LINE_OTHR_APLD_AMT4 |
Line Other Applied Amount for 4th Code |
| 58 |
LINE_OTHR_APLD_AMT5 |
Line Other Applied Amount for 5th Code |
| 59 |
LINE_OTHR_APLD_AMT6 |
Line Other Applied Amount for 6th Code |
| 60 |
LINE_OTHR_APLD_AMT7 |
Line Other Applied Amount for 7th Code |
| 61 |
LINE_RSDL_PYMT_IND_CD |
Line Residual Payment Indicator Code |
| 62 |
LINE_RP_IND_CD |
Line Representative Payee (RP) Indicator Code |
| 63 |
DMERC_LINE_FRGN_ADR_IND |
Line Foreign Address Indicator |
| 64 |
LINE_RR_BRD_EXCLSN_IND_SW |
Line Railroad Board Exclusion Indicator Switch |
| 65 |
LINE_VLNTRY_SRVC_IND_CD |
Line Voluntary Service Indicator Code |
| 66 |
DMERC_OXGN_EQUIP_INITL_DT |
Oxygen Equipment Initial Date |
| 67 |
DMERC_OXGN_INITL_DT_CD |
Oxygen Equipment Initial Date Code |
| 68 |
DMERC_OXGN_EQUIP_PRVS_DT |
Oxygen Equipment Previous Date |
| 69 |
CLM_NEXT_GNRTN_ACO_IND_CD1 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Population-Based Payment (PBP) |
| 70 |
CLM_NEXT_GNRTN_ACO_IND_CD2 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Telehealth |
| 71 |
CLM_NEXT_GNRTN_ACO_IND_CD3 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Post Discharge HH visits |
| 72 |
CLM_NEXT_GNRTN_ACO_IND_CD4 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - 3-day SNF waiver |
| 73 |
CLM_NEXT_GNRTN_ACO_IND_CD5 |
Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Capitation |